How The Aca Addressed Health Equity And What Repeal Would Mean

Commentary How the ACA Addressed Health Equity and What Repeal Would Mean Colleen M. Grogan University of Chicago Abstract This commentary reviews the many different ways the Affordable Care Act (ACA) explicitly and implicitly attempted to improve health equity, and then assesses how the Republican proposal to repeal and replace the ACA (the proposed American Health Care Act) would impact efforts to improve health equity. Although the American health care system still had a long way to go to achieve health equity, it may be argued that the ACA was a major step forward in creating new programs and regulations that had the potential to improve health equity. In stark contrast, Trumpcare makes no mention of health equity as a goal and—if passed—would result in an increase in health inequity. It would shamefully represent the first time in modern US history that a major federal health reform bill would actually move us further away from creating more equal access to health care coverage and toward reduced health equity. Keywords Trumpcare, ACA, health inequity In a bill that is 906 pages long one might think that the Affordable Care Act (ACA) would impact many different facets of our health care system, and of course it does, despite the media and political focus on the coverage components of the bill. While the coverage components are crucially important for improving health equity in the United States, the ACA provided new provisions across the policy spectrum to address health equity in a multipronged approach. As discussed in the Introduction of this special issue, there are multiple ways to approach achieving health equity: from focusing on creating a more inclusive and fair decision-making process to improve health equity to focusing on direct investments in vulnerable communities to create a Journal of Health Politics, Policy and Law, Vol. 42, No. 5, October 2017 DOI 10.1215/03616878-3940508 Ó 2017 by Duke University Press Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/42/5/985/508779/985grogan.pdf by U OF TX MD ANDERSON user on 21 May 2018 986 Journal of Health Politics, Policy and Law Health Equity under the ACA Means/Process Legal Structure Section 1557 Nondiscrimination Political Process/ Policy Decisions Disparities Reporting Plans to Eliminate Disparities Ends/Outcomes Treatment Decisions Policy Design PCORI Coverage Provisions Patient Inclusion (Progressive) Diverse Workforce Financing Cultural Competency (Progressive) Subsidies Patient Health Outcomes Population Health Effects/Outcomes PCORI Research to Track Health Disparities PPHF ACA Reforms Figure 1 Health Equity under the ACA more equal distribution of health outcomes. What should be fully appreciated about the ACA is that it indeed included provisions for improving health equity through creation of a fairer process and a more equal distribution of health outcomes, and also invested across multiple levels within the health care system (see fig. 1). In this short commentary I walk through some of the most important provisions of the law. This illustrates the magnitude of the ACA’s intent to impact health equity. While we can debate how well various provisions would have improved health equity (or will improve equity in the absence of repeal), it is clear that improving health equity was (and continues to be) a central goal of the ACA, and a number of provisions were implemented to achieve that goal. This is crucially important because you cannot begin to achieve a goal unless you place that goal in legislation, and create concrete implementation plans to begin the hard work. The ACA did that. Therefore, when the Congress debates total ACA repeal with or followed by a replacement b